Preoperative Hospital Research Articles

Perioperative Venous Thromboembolism in Ulcerative Colitis: A Multicenter Prospective Study in Japan.

Recently, the prevalence of venous thromboembolism (VTE) in Asian patients with inflammatory bowel disease (IBD) is gradually increasing. IBD surgery is a well-recognized risk factor for VTE. However, there are no prospective studies about VTE after surgery for ulcerative colitis (UC) in Asia. This multicenter prospective study aimed to clarify the prevalence and risk factors for perioperative VTE in UC surgery in Japan. A total of 134 patients with UC were included from January 1, 2013 to December 31, 2014. Preoperative screening was performed in all patients. In the perioperative period, standard VTE prophylaxis based on risk assessment was administered. The prevalence of pre- and postoperative VTE, its risk factors, and mortality rates were investigated. Perioperative deep vein thrombosis and pulmonary embolism were diagnosed in 15 (11.1%) and 1 patient (0.7%), respectively. All patients were asymptomatic. No surgery-related deaths were found (mortality rate 0%). Seven patients (5.2%) were diagnosed, and 8 (6.4%) during postoperative follow-up by ultrasonography or computed tomography. Forty-seven percent of VTE cases was developed preoperatively. A preoperative hospital length stay of over 5 days was a significant risk factor [P = 0.04; odds ratio: 8.26 (1.06-64.60)] for preoperative VTE. Postoperative deep vein thrombosis occurred in 8 of the 127 patients (6.4%). Six out of these 8 (75.0%) occurred after postoperative day 14. Perioperative blood transfusion was a significant risk factor [P = 0.04; odds ratio: 8.26 (1.06-64.60)] for postoperative VTE. A VTE-conscious perioperative management is as necessary in Asia as in Western countries.

Fetal Diagnosis is Associated with Improved Perioperative Condition of Neonates Requiring Surgical Intervention for Coarctation.

To define the relative importance of fetal diagnosis and comorbidities in severity of preoperative compromise, outcomes and hospitalization in neonatal coarctation of the aorta (CoA). Retrospective comparison of preoperative condition and postoperative course of neonates prenatally (PreDx n = 48) or postnatally diagnosed (PostDx n = 67) with CoA. Congenital and non-congenital comorbidities were adjusted for. Postnatal diagnosis was associated with preoperative mortality (n = 2), and severe acidosis (lactate > 5 mM or pH < 7.20) on multivariate analysis (OR 4.2 (1.3-14.4, p = 0.02), with extracardiac congenital anomalies also a risk factor (OR 3.2 (1.03-10, p = 0.044). Median age at operation was delayed in the PostDx group (PreDx 6.5 days (IQR 4-9) vs PostDx 10 days (IQR 6-17)). Only comorbid left heart disease and extracardiac congenital anomalies were associated with prolonged total length of hospital stay. Prenatal diagnosis is the major adjustable risk factor affecting preoperative condition in critical CoA but does not reduce length of stay.

180 Management of Open Fractures at Oxford University Hospitals NHS Trust Major Trauma Centre

Abstract Introduction This audit was developed after noticing patients with open fractures had poor neurovascular assessment documentation (non-specific, none post-manipulation), and to check these patients received appropriate antibiotics. Review of open fracture management guidelines identified areas to be improved. Method Pre-operative hospital management of open fractures was audited using the NICE (NG37) and joint BOAST/BAPRAS guidelines on open fracture management. Interventions were awareness and education of junior doctors and editing the Trauma Clerking Form to prompt appropriate management and documentation, followed by re-audit. Results 30 patients were assessed pre- and post-intervention. Correct antibiotic administration rate (93%vs97%) and speed (50% &amp;lt;2 hours where not given pre-hospital - in both groups) were similar. The initial neurovascular assessment frequency was identical (93%), however documentation of assessment of specific arteries (86%vs30%) and nerves (60%vs23%) and assessing all appropriate arteries (60%vs13%) and nerves (60%vs20%) improved. There were increased frequencies of documenting manipulation in A&amp;E (90%vs47%) and neurovascular assessment post-manipulation (90%vs16%). Tetanus cover (87%vs77%), photo availability (70%vs40%), and appropriate dressing use (47%vs27%) improved. Conclusions Antibiotic management was consistent and appropriate. There were improvements in frequency and quality of neurovascular assessment, tetanus cover, availability of photographs of injuries and appropriate dressings used. Overall, pre-operative hospital management of open fractures improved.

Clinical characteristics and long-term outcomes for patients who undergo cytoreductive surgery for thoracic meningiomas: a retrospective analysis.

Primary spinal meningiomas represent a rare indolent neoplasm usually situated in the intradural-extramedullary compartment. They have a predilection for afflicting the thoracic spine and most frequently present with sensory and/or motor symptoms. Resection is the first-line treatment for symptomatic tumors, whereas other clinical factors will determine the need for adjuvant therapy. In this study, the authors aimed to elucidate clinical presentation, functional outcomes, and long-term outcomes in this population in order to better equip clinicians with the tools to counsel their patients. This is a retrospective analysis of patients treated at the authors' institution between 1998 and 2018. All patients with thoracic meningiomas who underwent resection and completed at least one follow-up appointment were included. Multiple preoperative clinical variables, hospitalization details, and long-term outcomes were collected for the cohort. Forty-six patients who underwent resection for thoracic meningiomas were included. The average age of the cohort was 59 years, and the median follow-up was 53 months. Persistent sensory and motor symptoms were present in 29 patients (63%). Fifteen lesions were ventrally positioned. There were 43 WHO grade I tumors, 2 WHO grade II tumors, and 1 WHO grade III tumor; the grade III tumor was the only case of recurrence. The median length of hospitalization was 4 days. Seventeen patients (37%) were discharged to rehabilitation facilities. Thirty patients (65.2%) experienced resolution or improvement of symptoms, and there were no deaths within 30 days of surgery. Only 1 patient developed painful kyphosis and was managed medically. Ventral tumor position, new postoperative deficits, and length of stay did not correlate with disposition to a facility. Age, ventral position, blood loss, and increasing WHO grade did not correlate with length of stay. Outcomes are overall favorable for patients who undergo resection of thoracic meningiomas. Symptomatic patients often experience improvement, and patients generally do not require significant future operations. Tumors located ventrally, while anatomically challenging, do not necessarily herald a significantly worse prognosis or limit the extent of resection.

Characteristics and outcomes of acute appendicitis cases during the COVID-19 pandemic

Aim: Our aim in this study was to investigate the effects of the COVID-19 pandemic on acute appendicitis (AA) cases. Material and Methods: This study was designed as a single-center, retrospective, and observational study. The patients were divided into three groups relative to the date of the first COVID-19 case in Turkey, which was March 10, 2020 (Group A: before the pandemic;Group B: pandemic period;Group C: the same period one year before the pandemic). A total of 413 patients were included in the study. Results: In terms of treatment modality, the rate of open appendectomy was significantly higher in Group B (p<0.001). Rates of conversion to open surgery, as well as rates of complicated appendicitis were also significantly higher in Group B (p=0.027, p=0.024, respectively). While there was no difference between the groups in terms of preoperative hospitalization duration (p=0.102), it was found that the duration of symptoms, operation time, and postoperative length of hospital stay were significantly higher in Group B (p<0.001, p=0.011, p=0.001, respectively). In addition, the complication rate in group B (8.9%) was also significantly higher than in the other two groups (p=0.023). Discussion: We found that the rate of open surgery, the rate of conversion of laparoscopic surgery to open surgery, complication rates, mean operation time, and postoperative hospital stay were significantly higher in AA patients that underwent surgery during the COVID-19 pandemic period. We believe that the main reason for this negative outcome is the late admission of the patients to the hospital.

The Significant Prognostic Factors in Prolonged Intensive/High Care Unit Stay After Living Donor Liver Transplantation

Prolonged stay in an intensive/high care unit (ICU/HCU) after living donor liver transplantation (LDLT) is a significant event with possible mortality. Adult-to-adult LDLTs (n=283) were included in this study. Univariate and multivariate analyses were performed for the factors attributed to the prolonged ICU/HCU stay after LDLT. Recipients who stayed in the ICU/HCU 9 days or longer were defined as the prolonged group. The prolonged group was older (P=.0010), had a higher model for end-stage liver disease scores (P < .0001), and had higher proportions of patients with preoperative hospitalization (P < .0001). Delirium (P < .0001), pulmonary complications (P < .0001), sepsis (P < .0001), reintubation or tracheostomy (P < .0001), relaparotomy due to bleeding (P=.0015) or other causes (P < .0001), and graft dysfunction (P < .0001) were associated with prolonged ICU/HCU stay. Only sepsis (P=.015) and graft dysfunction (P=.019) were associated with in-hospital mortality among patients with prolonged ICU/HCU stay or graft loss within 9 days of surgery. Among these patients, grafts from donors aged <42 years and with a graft-to-recipient weight ratio of >0.76% had significantly higher graft survival than grafts from others (P=.0013 and P < .0001, respectively). Prolonged ICU/HCU stay after LDLT was associated with worse short-term outcomes. The use of grafts of sufficient volume from younger donors might improve graft survival.

Omentopexy during laparoscopic sleeve gastrectomy: Is it effective in reducing postoperative gastrointestinal symptoms. A retrospective cohort study

BackgroundPostoperative gastrointestinal symptoms are common in patients undergoing sleeve gastrectomy. This study is aimed to assess the effectiveness of omentopexy during laparoscopic sleeve gastrectomy in reducing gastrointestinal symptoms. MethodsA retrospective analysis of patients who underwent laparoscopic sleeve gastrectomy with and without omentopexy in the period between January 2016 to September 2017. All procedures were performed by three surgeons utilizing the same surgical technique. Data extracted included patient socio-demographics’, preoperative body mass index (BMI), hospitalization period, treatments and post-operative gastrointestinal symptoms. It contained the GERD-Health Related Quality of Life Questionnaire (GERD-HRQL) measuring symptom severity in gastro esophageal reflux disease (GERD). Data were analyzed at 6, 12 and 18 months with reference to weight loss. ResultsA total of 140 patients were included in this study, 70 in each group arm. Age, preoperative BMI, pre-operative co-morbid conditions like hypertension, diabetes, and asthma were considered as confounding variables among the two groups. None of the previous factors were statistically significantly different among both groups. The outcomes of both groups were compared in terms of postoperative nausea, vomiting, regurgitation, intra-hospital stay, medication use, early return to work, and EWL%. None of the previous outcomes except for days of hospital stay and ondansetron use was found to be significantly different between both groups. ConclusionOmentopexy does not change the outcome for laparoscopic sleeve gastrectomy in terms of gastrointestinal symptoms or weight loss results.

Reversal of end-ileostomy in patients with Crohn's disease.

End-ileostomy after two-staged ileocolic resection is frequently performed in Crohn's disease patients at high risk for postoperative complications. However, there is paucity on data regarding the morbidity after the stoma reversal. One hundred thirty patients undergoing closure of end-ileostomy between 1994 and 2016 were included. Data collection was retrospective in 11 first, and it was prospective in 119 last patients. Anastomotic complications were defined as anastomotic leak, perianastomotic abscess, and perianastomotic peritonitis. The median interval between ileostomy construction and reversal was 4.0months. Ninety-seven of 121 patients with available data (80%) gained weight between both surgeries. Hemoglobin level increased between surgeries in 107 patients (85%). Fifteen patients (11.5%) received parenteral fluid substitution or parenteral nutrition between both surgeries. There were 37 hospital readmissions during the time between stoma construction and reversal (29%). After ileostomy reversal, 14 patients developed anastomotic complications (11%). By multivariate regression analysis, preoperative steroid intake (hazard ratio 4.5, 95% CI: 1.11-18.0, p= 0.035) and hospital readmission for infectious complications (HR 4.5, 95% CI: 1.11-18.0, p = 0.035) were statistically significantly associated with an increased risk to develop postoperative anastomotic complications. There were no postoperative deaths. Closure of end-ileostomy could be complicated by some serious morbidity. These risks should be taken into consideration weighing carefully between the one- and two-stage ileocolic resection in Crohn's disease patients.

Prognostic Indicators of Delayed Surgical Recovery in Patients Undergoing Cardiac Surgery.

The purpose of this study was to analyze the prognostic capacity of the clinical indicators of a delayed surgical recovery nursing diagnosis throughout the hospital stay of patients having cardiac surgery. A prospective cohort design was adopted. A sample of inpatients undergoing elective cardiac surgery was followed during the immediate preoperative period and hospitalization. This research was conducted in the southeast region of Brazil at a national reference institution that treats highly complex diseases and performs cardiac surgeries. Data were collected from July 2017 to July 2018. At the end of 1 year of data collection, 181 patients were followed in this study. The Kaplan-Meier method was used to calculate the survival time related to delayed surgical recovery. In addition, an extended Cox model of time-dependent covariates was adjusted to identify the clinical signs that influenced the change in the nursing diagnosis status. A delayed surgical recovery nursing diagnosis was present in 23.2% of the sample studied. With an expected length of stay of 8 to 10 days, most new cases of delayed surgical recovery were observed on the 10th postoperative day, and the survival rate after this day was decreased until the 29th postoperative day, when the nursing diagnosis no longer appeared. Interrupted healing of the surgical area, loss of appetite, and atrial flutter were indicators related to an increased risk for delayed surgical recovery. Timely recognition of selected clinical indicators demonstrates a promising prognostic capacity for delayed surgical recovery. Accurate identification of prognostic factors allows nurses to identify early signs of postoperative complications. Consequently, the professional can develop an individualized plan of care, aiming at the satisfactory clinical recovery of the patient.

Pulmonary infection after cardiopulmonary bypass surgery in children: a risk estimation model in China

ObjectivesThe occurrence of pulmonary infection after congenital heart disease (CHD) surgery can lead to significant increases in intensive care in cardiac intensive care unit (CICU) retention time, medical expenses, and risk of death risk. We hypothesized that patients with a high risk of pulmonary infection could be screened out as early after surgery. Hence, we developed and validated the first risk prediction model to verify our hypothesis.MethodsPatients who underwent CHD surgery from October 2012 to December 2017 in the Children’s Hospital of Chongqing Medical University were included in the development group, while patients who underwent CHD surgery from December 2017 to October 2018 were included in the validation group. The independent risk factors associated with pulmonary infection following CHD surgery were screened using univariable and multivariable logistic regression analyses. The corresponding nomogram prediction model was constructed according to the regression coefficients. Model discrimination was evaluated by the area under the receiver operating characteristic curve (ROC) (AUC), and model calibration was conducted with the Hosmer-Lemeshow test.ResultsThe univariate and multivariate logistic regression analyses identified the following six independent risk factors of pulmonary infection after cardiac surgery: age, weight, preoperative hospital stay, risk-adjusted classification for congenital heart surgery (RACHS)-1 score, cardiopulmonary bypass time and intraoperative blood transfusion. We established an individualized prediction model of pulmonary infection following cardiopulmonary bypass surgery for CHD in children. The model displayed accuracy and reliability and was evaluated by discrimination and calibration analyses. The AUCs for the development and validation groups were 0.900 and 0.908, respectively, and the P-values of the calibration tests were 0.999 and 0.452 respectively. Therefore, the predicted probability of the model was consistent with the actual probability.ConclusionsIdentified the independent risk factors of pulmonary infection after cardiopulmonary bypass surgery. An individualized prediction model was developed to evaluate the pulmonary infection of patients after surgery. For high-risk patients, after surgery, targeted interventions can reduce the risk of pulmonary infection.

Factors Affecting Patient Outcomes in Acute Appendicitis in Rural Areas: An Observational Cohort Study

The most common surgical emergency both in developed and non-developed countries is acute appendicitis and it has a time-dependent clinical course. In this observational cohort study, we aim to investigate the factors affecting patient outcomes in acute appendicitis at a rural hospital. This observational cohort study was held between November 2012 and May 2014 at a rural hospital. Patients' pre-operative, perioperative, and post-operative data were collected prospectively. Patients were followed-up for 12-months. A total of 151 patients were recorded. Factors significantly associated with complicated cases (abscess/perforation) were referral region as remote towns (OR:7.94, 95%CI [3.46-18.23]; p < 0.001), referral season as winter (OR:2.47, %95CI [1.14-5.36]; p = 0.022), pre-operative hospital delay (OR:6.52, 95%CI [3.49-12.20]; p < 0.001), and duration of referral (OR:1.01, 95%CI [1.00-1.01]; p < 0.001). In the multivariate analysis, only pre-operative hospital delay remained as a significant factor (OR:5.87, 95%CI [2.85 - 12.07]; p < 0.001). Factors affecting length of hospital stay (LoHS) were referral region as remote towns (95%CI, β = 3.10 [2.28-3.93], t = 1.91; p < 0.001), abscess/perforation (95%CI, β = 4.70 [4.04-5.36], t = 14.05; p < 0.001), pre-operative hospital delay (95%CI, β = 1.25 [0.87-1.62], t = 6.58; p < 0.001), and duration of referral (95%CI, β = 0.011 [0.01-0.14], t = 7.34; p < 0.001). In the multivariate analysis, all four factors stayed significant. The rate of complicated appendicitis was significantly high in winter than other seasons for patients referring from remote towns (75% vs 33%, p < 0.001). This observational cohort study is the only study specifically focused on the effect of season and region on abscess/perforation rates, LoHS, and accessibility to hospital in patients with acute appendicitis.

Risk factors, bacteriological profile and outcome of surgical site infections following orthopaedic surgery.

Background and Objectives:Surgical site infection (SSI) is a challenge for the surgeon. Incidence of SSI reported in literature varies from 0.5% to 15%. Severity of SSI ranges from superficial skin infection to life-threatening condition like septicaemia. It is responsible for increased morbidity, mortality, and economic burden to the hospital in general, and the patient in particular. The aim of this study was to assess the risk factors, bacteriological profile, length of hospitalization, and cost due to orthopaedic SSI in patients admitted to a tertiary care hospital.Materials and Methods:This was a prospective case control study. Cases were diagnosed based on CDC definition of nosocomial SSI. All cases were assessed preoperatively, intraoperatively and postoperatively, according to type of surgery, wound class, duration of operation, antimicrobial prophylaxis, use of drain, preoperative hospital stay, causative micro organism, total hospital stay, readmission rates and cost incurred. Age, sex and surgical procedure matched controls without SSI, were also assessed. Chi-square test and Fisher’s exact test were used for analysis. P= <0.05 was considered significant.Results:Out of 1023 patients, 47 cases had SSI, with a rate of 4.6%. Cigarette smoking was a risk factor for SSI (P = 0.0035). The most common etiologic agents were Acinetobacter baumannii and Staphylococcus aureus. Incidence of readmission among SSI cases was more compared to controls (P= 0.0001). Costs attributable to SSI (Indian Rupees) was Rs 32,542 (17,054 to 87,514) which was significantly more than those without SSI (P= <0.001).Conclusion:Despite latest surgical amenities, meticulous sterilization protocols and pre-operative antibiotic prophylaxis, SSI continues to be present in healthcare settings. The increase in duration of hospital stay due to SSI adds to additional burden to an already resource-constrained healthcare system.

A polysomnography study examining the association between sleep and postoperative delirium in older hospitalized cardiac surgical patients.

Hospitalized older patients who undergo elective cardiac surgery with cardiopulmonary bypass are prone to postoperative delirium. Self-reported shorter sleep and longer sleep have been associated with impaired cognition. Few data exist to guide us on whether shorter or longer sleep is associated with postoperative delirium in this hospitalized cohort. This was a prospective, single-site, observational study of hospitalized patients (>60years) scheduled to undergo elective major cardiac surgery with cardiopulmonary bypass (n=16). We collected and analysed overnight polysomnography data using the Somté PSG device and assessed for delirium twice a day until postoperative day 3 using the long version of the confusion assessment method and a structured chart review. We also assessed subjective sleep quality using the Pittsburg Sleep Quality Index. The delirium median preoperative hospital stay of 9 [Q1, Q3: 7, 11] days was similar to the non-delirium preoperative hospital stay of 7 [4, 9] days (p=.154). The incidence of delirium was 45.5% (10/22) in the entire study cohort and 50% (8/16) in the final cohort with clean polysomnography data. The preoperative delirium median total sleep time of 323.8 [Q1, Q3: 280.3, 382.1] min was longer than the non-delirium median total sleep time of 254.3 [210.9, 278.1] min (p=.046). This was accounted for by a longer delirium median non-rapid eye movement (REM) stage 2 sleep duration of 282.3 [229.8, 328.8] min compared to the non-delirium median non-REM stage 2 sleep duration of 202.5 [174.4, 208.9] min (p=.012). Markov chain modelling confirmed these findings. There were no differences in measures of sleep quality assessed by the Pittsburg Sleep Quality Index. Polysomnography measures of sleep obtained the night preceding surgery in hospitalized older patients scheduled for elective major cardiac surgery with cardiopulmonary bypass are suggestive of an association between longer sleep duration and postoperative delirium.

Left Ventricular Assist Device Exchange to HeartMate III Using Minimally Invasive Approach

<h3>Purpose</h3> Pump thrombosis, infection or device malfunction are major complications of LVAD that may need to be treated with pump exchange. There is limited data on exchanges to HMIII. Our purpose was to review outcomes of patients undergoing any LVAD to HMIII exchange at our center using minimally invasive approach (subcostal and/or left anterolateral thoracotomy). <h3>Methods</h3> We retrospectively reviewed records of patients undergoing any LVAD to HMIII exchange from January 2016 to October 2020. Pre-operative characteristics, indication, hospitalization course and post discharge data was collected. <h3>Results</h3> Ten patients underwent LVAD (7 HMII, 2 HMIII, 1 HeartWare) to HMIII exchange. Baseline characteristics are described in Table 1. Indications for exchange were pump thrombosis (3), infection + thrombosis (2), malposition (1), malposition + thrombosis (1), outflow graft obstruction from external compression (1), outflow graft twisting and thrombosis (1) and drive line injury (1). All patients underwent minimally invasive approach but 5 needed additional sternotomy to clear abscess collection or due to anatomical complexity. Post exchange, 1 patient needed pericardial window, 1 needed short term hemodialysis, 1 had recurrence of GI bleeding, 1 had CVA on POD 1 and 3 patients needed washout and debridement or hematoma evacuation. There was no change in RV function. Mean length of stay was 20.8 ±2 days. There was only 1 re-admission (sternal wound drainage needing debridement) within 30 days of discharge. There were a total of 8 other admissions (2 for MSSA Bacteremia, 1 for HF exacerbation, 1 for GI bleeding, 1 repeat debridement of sternal wound, 1 for renal failure and 2 for unrelated reasons) within 1 year post discharge. There was no recurrence of thrombosis. Mortality was 0% at 30 days and 0% at 1 year for 5/10 patients (others are alive and less than 1 year from exchange). <h3>Conclusion</h3> LVAD to HMIII exchange with a minimally invasive approach has low surgical mortality and acceptable intermediate- term outcomes.

Tracheostomy in Postoperative Pediatric Cardiac Surgical Patients—The Earlier, the Better

AbstractObjectives This study was aimed to assess the benefits of early tracheostomy (ET) compared with late tracheostomy (LT) on postoperative outcomes in pediatric cardiac surgical patients.Design Present one is a prospective, observational study.Setting The study was conducted at a cardiac surgical intensive care unit (ICU) of a tertiary care hospital.Participants All pediatric patients below 10 years of age, who underwent tracheostomy after cardiac surgery from January2019 to december2019, were subdivided into two groups according to the timing of tracheostomy: “early” if done before 7 days or “late” if done after 7 days postcardiac surgery.Interventions ET versus LT was measured in the study.Results Out of all 1,084 pediatric patients who underwent cardiac surgery over the study period, 41 (3.7%) received tracheostomy. Sixteen (39%) patients underwent ET and 25 (61%) underwent LT. ET had advantages by having reduced risk associations with the following variables: preoperative hospital stay (p = 0.0016), sepsis (p = 0.03), high risk surgery (p = 0.04), postoperative sepsis (p = 0.001), C-reactive protein (p = 0.04), ventilator-associated pneumonia (VAP; p = 0.006), antibiotic escalation (p = 0.006), and antifungal therapy (p = 0.01) requirement. Furthermore, ET was associated with lesser duration of mechanical ventilation (p = 0.0027), length of ICU stay (LOICUS; p = 0.01), length of hospital stay (LOHS; p = 0.001), lesser days of feed interruption (p = 0.0017), and tracheostomy tube change (p = 0.02). ET group of children, who had higher total ventilation-free days (p = 0.02), were decannulated earlier (p = 0.03) and discharged earlier (p = 0.0089).Conclusion ET had significant benefits in reduction of postoperative morbidities with overall shorter mechanical ventilation, LOICUS, and LOHS, better nutrition supplementation, lesser infection, etc. These benefits may promote faster patient convalescence and rehabilitation with reduced hospital costs.

Associations between preoperative anaemia and hospital costs following major abdominal surgery: cohort study.

BackgroundDetermining the cost-effectiveness and sustainability of patient blood management programmes relies on quantifying the economic burden of preoperative anaemia. This retrospective cohort study aimed to evaluate the hospital costs attributable to preoperative anaemia in patients undergoing major abdominal surgery.MethodsPatients who underwent major abdominal surgery between 2010 and 2018 were included. The association between preoperative patient haemoglobin (Hb) concentration and hospital costs was evaluated by curve estimation based on the least-square method. The in-hospital cost of index admission was calculated using an activity-based costing methodology. Multivariable regression analysis and propensity score matching were used to estimate the effects of Hb concentration on variables related directly to hospital costs.ResultsA total of 1286 patients were included. The median overall cost was US $18 476 (i.q.r.13 784–27 880), and 568 patients (44.2 per cent) had a Hb level below 13.0 g/dl. Patients with a preoperative Hb level below 9.0 g/dl had total hospital costs that were 50.6 (95 per cent c.i. 14.1 to 98.9) per cent higher than those for patients with a preoperative Hb level of 9.0–13.0 g/dl (P < 0.001), 72.5 (30.6 to 128.0) per cent higher than costs for patients with a Hb concentration of 13.1–15.0 g/dl (P < 0.001), and 62.4 (21.8 to 116.7) per cent higher than those for patients with a Hb level greater than 15.0 g/dl (P < 0.001). Multivariable general linear modelling showed that packed red blood cell (PRBC) transfusions were a principal cost driver in patients with a Hb concentration below 9.0 g/dl.ConclusionPatients with the lowest Hb concentration incurred the highest hospital costs, which were strongly associated with increased PRBC transfusions. Costs and possible complications may be decreased by treating preoperative anaemia, particularly more severe anaemia.

Minimally invasive surgery for choledochal cysts: Laparoscopic versus robotic approaches.

Backgrounds/AimsMinimally invasive surgery is a widely accepted approach in hepatobiliary surgery and choledochal cyst excision has also been performed by minimally invasive methods, including laparoscopic and robotic approaches. However, only a few studies have compared laparoscopic and robotic surgery. Therefore, we performed a comparative study between two groups, including cost aspects.MethodsWe retrospectively analyzed minimally invasive choledochal cyst excision at Severance Hospital in Seoul, South Korea from January 2005 to December 2018. A total of 39 patients that underwent minimally invasive choledochal cyst excision were identified. The 23 patients (58.9%) and 16 patients (41.1%) were enrolled in laparoscopic and robotic approach, respectively. We compared the patient’s characteristics, and perioperative outcomes between laparoscopic and robotic surgery groups.ResultsA comparative analysis between the two groups showed no differences in preoperative clinical characteristics. There were no significant differences in operative time, estimated blood loss, and postoperative complications, including biliary complication. The preoperative ASA score (p=0.021) and hospital stays (p=0.011) were the only clinical variables that differed between the two groups. All of the variables included in the cost analysis showed statistically significant differences (total hospital charge: p=0.035, patient’s bill: p≤0.001, operation: p=0.002, anesthesia: p=0.001, postoperative management: p=0.001).ConclusionsThe overall clinical outcomes between the laparoscopic and robotic approach to choledochal cyst were comparable. The surgical approach should be balanced based on the surgeons’ skill, patients’ general condition, disease extent, and economic status.

Risk factors of postoperative delirium after liver transplantation: a systematic review and meta-analysis.

The aim of this study was to summarize the incidence and risk factors of postoperative delirium (POD) after liver transplantation (LT) and associations of POD after LT with outcomes. A literature search of Pubmed, EMBASE, and the Cochrane Databases was performed to identify studies reporting POD after LT. The Newcastle-Ottawa Scale was used to rate study quality. Effect estimates were extracted and combined using random-effect model. Pooled mean differences and odds ratios for individual risk factors were calculated using inverse-variance method and Mantel-Haenszel method, as appropriate. Eight articles with 1434 patients were included in the meta-analysis. Overall, the pooled estimated incidence rates of POD after LT were 30% (95% confidence interval: 20-39%). Fourteen statistically significant risk factors were identified in the pooled analysis: alcohol excess, preoperative renal replacement therapy (RRT), preoperative hospital length of stay (LOS), depression, hepatic encephalopathy, alcohol etiology of liver failure, Child-Turcotte-Pugh Score, APACHE II Score, MELD Score, preoperative INR, preoperative bilirubin, intraoperative use of fentanyl, intraoperative RBC transfusion, postoperative ammonia. Patients with POD had a significantly increased mechanical ventilation, postoperative RRT, LOS and mortality rate compared with those without POD. POD after LT was common and multifactorial in etiology. There are significant associations of POD after LT with some clinical outcomes. Effective interventions during perioperative period may be promising to reduce the risk of POD after LT.

Studying Enhanced Recovery After Surgery (ERAS\xae) Core Items in Colorectal Surgery: A Causal Model with Latent Variables

BackgroundPrevious Enhanced Recovery After Surgery (ERAS®) studies have not always taken into account that ERAS interventions depend on baseline covariates and that several confounding variables affect the composite outcomes.MethodA causal latent variable model is proposed to analyze data obtained prospectively concerning 1261 patients undergoing elective colorectal surgery within the ERAS protocol. Primary outcomes (composite of any complication, surgical site infection, medical complications, early ready for discharge (TRD), early actual discharge) and secondary outcomes (composite of late bowel function recovery, IV fluid resumption, nasogastric tube replacement, postoperative nausea and vomiting, re-intervention, re-admission, death) are considered along with their multiple dimensions.ResultsConcerning the primary outcomes, our results evidence three subpopulations of patients: one with probable good outcome, one with possibly prolonged TRD and discharge without complications, and the other one with probable complications and prolonged TRD and discharge. Epidural anesthesia, waiving surgical drainage, and early ambulation, IV fluid stop and urinary catheter removal act favorably, while preoperative hospital stay and blood transfusion act negatively. Concerning the secondary outcomes our results evidence two subpopulations of patients: one with high probability of good outcome and one with high probability of complications. Epidural anesthesia, waiving surgical drainage, early ambulation and IV fluid stop act favorably, while blood transfusion acts negatively also with respect to these secondary outcomes.ConclusionThe multivariate causal latent class two-parameter logistic model, a modern statistical method overcoming drawbacks of traditional models to estimate the average causal effects on the treated, allows us to disentangle subpopulations of patients and to evaluate ERAS interventions.

Laparoscopic simple prostatectomy: a large single-center prospective cohort study.

BACKROUND The aim of our study was to analyze outcomes and safety of laparoscopic simple prostatectomy (LSP) in a high-volume center. METHODS A consecutive series of men with lower urinary tract symptoms and large prostates (>80 cc) prospectively enrolled between November 2015 and December 2017 in one center. All patients underwent laparoscopic simple prostatectomy. Outcomes were evaluated considering the trifecta favorable outcome which was defined as a combination of the following items: 1) no perioperative complications; 2) postoperative IPSS max >15 mL/s. Complications were evaluated according to the modified Clavien classification system. Univariate and multivariate binary logistic regression was performed to identify predictors of a positive trifecta outcome. RESULTS Overall 272 patients were enrolled. At three months after surgery median IPSS total score was 4 (IQR: 3-7), median IPSS QoL was 1 (IQR:1-2), median prostate-specific antigen was 0.53 (IQR: 0.33-1.00) ng/ml and median Q max was 23 (IQR: 17-30) mL/s. All these parameters improved statistically when compared to baseline (P<0.001). The overall complication rate was 21% however most of the complications were low grade complications according to modified Clavien-Dindo classification (grade ≤2). Overall, 68% of the patients presented a positive trifecta outcome. On multivariate analysis only preoperative hemoglobin and hospital stay were confirmed predictors of positive trifecta outcome. CONCLUSIONS LSP represents a safe and effective procedure in the treatment of large adenomas. Although RCTs are needed before reaching definitive conclusions, LSP is a promising technique for patients with LUTS and large prostates.